Guest Discussion: ESL as Mechanism for Advancing Health Literacy

Thanks, Kat, for sharing your thoughts. Based on our teacher survey, we found that the majority of teachers were interested in the integration of diabetes prevention content into their teaching, but a smaller proportion of teachers felt they knew where to look for reliable materials they could use in the classroom.  Did you need to augment the New Readers Press textbook with outside materials, and if so, what materials did you use?

And to others on the list, would you agree that there's a need to improve access to diabetes prevention materials for adult ESL/literacy teachers? What kinds of resources or materials would you like to have? And what's the best way to disseminate these materials?

Thanks, Miriam, for your comment and question.  I'm glad you brought up the possibility that not all learners are going to feel comfortable assessing their own risk in ESL class. We adapted the risk assessment put out by the American Diabetes Association; we wanted learners to have the opportunity to take the risk assessment but did not force anyone to share his/her scores.  

In our lesson planning with the teachers, we spent considerable time talking about what kinds of activities would promote understanding of risk, promote sharing of questions about risk, without pressuring students to talk about their own personal risk profile.  We read a real-life short story of an ESL learner, Eugenia, who also was union organizer and the mother of 2 young boys. In her own words, Eugenia talks about her worries: Can I be a good organizer if I am sick? Will my boys get diabetes too? This activity, created by a colleague Alison Webber of Building Skills Partnership using Gail Weinstein's Learners' Lives as Curriculum framework, is able to (1) help learners develop language for talking about risk; and (2) help normalize the discussion of personal risk in a less threatening way.  Our teachers also developed an "imaginary profile" activity, which featured demographic profiles for Eugenia and 2-3 "imaginary" people:

For example:

Minsun
Height: 5'0"
Weight: 135 pounds
Age: 77
Daily exercise: No
Baby weight: 6 pounds
Siblings have diabetes? Yes
Parents have diabetes? No

The learners practice calculating risk scores for each of the people featured on the worksheet.  (You probably already noticed that there's some interesting math involved in this lesson too). The learners could work in small groups and make up new "imaginary" profiles which could be then shared with other groups.  

Miriam's comment reminds us that, as teachers, we need to attend carefully to the nature of the conversations that learners are having around health content.  For me, I need to be able to keep in check my own excitement about/fascination with cultural perceptions of risk when developing lesson plans. I've learned how essential it is to attend to the nature of the learners' talk and interaction around the health content.  What content vocabulary about risk do they minimally need to react to Eugenia's story? What kinds of language can we teach so they are equipped to ask questions about risk? How can stories like Eugenia's serve as the template for telling their own stories about risk? (These are the kinds of questions inspired by Gail's Learners' Lives as Curriculum framework, which we have continued to use in our curricular planning).  Can I readily configure group work in the classroom so that learners have an opportunity to learn about risk from multiple learners in the room (e.g., older learners, younger learners, those who have been in the U.S. for many years versus a few months)?

More recently, I have been working with a colleague, David Olsher, at SF State who is a classroom discourse analyst. We are shifting our attention to the learners' social interactional patterns and language use during group work in diabetes-focused ESL classrooms.  We're still busy transcribing, but our sense is that learners appear to use an array of language practices that serve to personalize the health content in a meaningful way.  Examples of language practices include: clarifying task procedures, repeating new vocabulary, agreeing or disagreeing with an idea, giving advice, repeating a story, telling a new story...  Our idea is that health literacy is a kind of discursive reasoning which requires all of us (learners and non-learners!) to integrate health content with personal life experience. Even though our learners are not yet skilled users of English, their classroom learning has much to teach us about the importance of talk and engagement with others in our understanding of health literacy. 

Thanks, maricel

Having worked with Maricel in this arena, I too have noticed the incredible 'spill over' of collective health literacy skill development in ESL classrooms and welcome further conversation about how to best characterize the "achievement of health literacy gains that is shared across individuals".  

In the public health field, while there is much said about collective impact and there is a real desire to develop community-level measures of impact, there are few examples that can help explore mechanisms and facilitators of health literacy skill development. Indeed, this is an area where ESL communities could help advance this area of health literacy scholarship and practice. 

Gosh, when we were working on this project, the framing of functional literacy vs. social practice wasn't as clear to me as it is in the paper.  But Maricel definitely encouraged the teachers to move beyond information transmission and to get students to question.  And I gather that's part of teaching literacy as social practice.

Here are a couple of examples to illustrate how I accomplished this in a low beginning level ESL class.  Contrasting the two may show the difference between functional literacy and literacy as social practice.  The content is exercise; the grammar is simple present tense.

I hope the links work.  Sorry the document formatting gets messed up in the uploading process.

Exercise half page

With this handout, students learn vocabulary for different types of exercise.  They also reinforce their recently-learned knowledge of the simple present tense by asking each other, in pairs, "What does he do for exercise?" "He runs," etc.

Exercise or Not half page

With this handout, students learn more vocabulary for activities, of which some are obviously NOT exercise, and others may or may not be exercise, depending on the speakers' viewpoint.  Pairs asked each other, "Is this exercise?" the response being either, "Yes, it is," or "No, it isn't."

The activity was designed to get my students thinking about what kinds of activity in their daily lives may constitute exercise -- a theme that's expanded upon later in the unit.  I also hoped it would generate some difference of opinion to, in turn, at this very beginning level, promote some discussion.  And it did.  For example, we had male/female difference of opinion about whether cleaning house and making beds is exercise.  And it surprised ME that my students overwhelmingly said that working construction (as opposed to, say, lifting boxes) is NOT exercise.  (My guess is that the workers in the picture I used look like they have good union jobs my students are envious of.)

Hi Julie and everyone!

I am one of the teachers who worked with Maricel on this project. I teach at a community-based organization created by and for Latina immigrant women, whose programs are built on the idea that immigrants themselves are uniquely equipped to find solutions to the issues that affect them. The health literacy as social practice model is a great fit for my organization, as opposed to a model where experts from outside the community would just transmit information on diabetes to the students.   

In my class, the starting point for our discussion on diabetes was the story of Claudia, one of our members. She is the President of the Board of Directors of our organization, and was a domestic worker at the time. The story describes her busy schedule as a domestic worker and single mom, and how her busy life prevented her from exercising and eating well. After being told by her doctor that she was at risk for gestational diabetes, she dramatically changed her lifestyle, started eating healthier food, exercising, losing weight and feeling better.

This story was a gateway for discussion, as most women in my class felt identified with Claudia, and several of them revealed that they were also diagnosed with pre-diabetes or diabetes, or that the disease runs in their families. The story allowed us to do language work mostly around idioms, verbs in the present tense and interrogative sentences.

Students prepared questions to ask Claudia as well as Diana, a health practitioner from UCSF who specializes in gestational diabetes and is bilingual in English and Spanish. The project ended with a bilingual Q&A session between Claudia, Diana and the class participants. By the end of the project, participants had collectively come up with self-care strategies, brainstormed ways to incorporate self-care activities into their busy lives and shared resources on eating well and exercising. 

Thanks, Julie, for bringing in collective efficacy here. While we have not referred to this particular concept in our work thus far, it's a highly relevant concept for understanding one possible mechanism by which health literacy instruction in ESL classrooms can have a positive impact on a learners' health literacy skills/practice, their preventive health behaviors, and ultimately, their health and well-being. The concept enables us to appreciate the possibility that health literacy instruction in ESL may benefit learners by giving them a greater sense of control over the direction of their health care and well-being. As part of pre/post surveys, we asked learners Do you have plans to change your eating (exercise) habits? and If yes, how confident are you that you will make this change? Accounting for changes in confidence represents one way we accounted for changes in perceived control.  Over 90% of the learners who said they had plans to change their eating/exercise habits reported feeling confident to very confident about doing so.  But please note that "Many learners indicated they already had healthy nutrition and exercise habits at baseline, suggesting the ESL lessons reinforced health habits in addition to supplanting less healthy ones" (p. 99).  

Building on Marcia Hohn's study, it's exciting to imagine how we -- through our curriculum development and classroom-based research -- might be able to demonstrate that "collective efficacy" is a key factor that links ESL participation and health outcomes.  Such evidence would build the argument that ESL participation can be viewed as a health-protective factor in immigrant communities.  This reminds me of a 2000 study that was conducted by two public health researchers Deborah Bender and Dina Castro entitled "Explaining the birth weight paradox: Latina Immigrants' perceptions of resilience and risk".  The researchers explored the perceptions of resilience among Latina women who had recently immigrated to the U.S., and the possible links between sources of resilience and health.  They found that ESL participation was an important source of resilience for the women:

Several of the [women] did talk about the importance of learning English. For these women, not only were ESL lessons helpful, but the Americans who worked with them were identified as a helpful and highly valued resource in making sense of and managing the dominant U.S. culture. Asking for assistance with studying for a driver’s license, help with adjustments to bills, and understanding which and why certain forms were necessary for completion of a particular application were among the tasks for which the Latina women had requested assistance. Although the ESL training itself helped respondents to adapt to their new surroundings, the support offered by the ESL volunteers seems to offer at least some of the ‘‘emotional support outside the family’’ and the ‘‘encouragement of autonomy’’ that is thought to promote resilience in stressful circumstances. (p. 172)
 

I imagine Bender & Castro's findings will not surprise anyone who has worked in ESL/adult literacy.  The value placed on classroom community is a strength of many ESL classrooms.  I'd love to hear how others have thought about the promotion of collective efficacy or the promotion of resilience in our ESL classrooms. Best, Maricel